Contamination of a drug consumption room with drugs and potential risks for social health care workers.

BACKGROUND: Studies have shown that contamination of surfaces by illicit drugs frequently occurs in forensic laboratories when manipulating seized samples as well as in pharmacies and hospitals when preparing medicinal drugs. In this project, we extended these studies to a Drug Consumption Room to investigate drug levels and possible exposure of the staff members. METHODS: We investigated pre and post cleaning contamination by heroin and cocaine and their degradation products 6-monoacetylmorphine and benzoylecgonine on different surfaces (tables, counters, computers and door handles) and in the ambient air. We also collected urine and hair samples from staff members to check for potential short and long term contaminations. RESULTS: Medium to heavy contamination has been detected on most surfaces and door handles; as expected, air contamination was particularly high in the smoking room. Drug levels were < LOD to very low in the urine and the hair samples of staff members tested. CONCLUSION: The cleaning efficiency of the surfaces, carried out by staff and drug users after drug consumption, was often not satisfactory. The very low drug levels in hair indicate that acute health risks for staff members are low.

Consumer expectations, drug effects, price and purity of heroin and cocaine purchased at drug consumption rooms.

BACKGROUND: Drug consumption rooms offer heroin and cocaine consumers a secure and hygienic environment including medical and social guidance. Despite the support and mentoring, only sparse information is available about how drug quality, drug prices and user expectations match at these locations. The present study reports analysis of these three parameters in two drug consumption rooms in Luxembourg. METHODS: Drug users were invited to participate in the project by handing in a few milligrams of the product they planned to consume for chemical analysis and filling out a short questionnaire about the price and their expectations. After consumption, they were asked to report the experienced effects. Drug quality was accessed using LC-Q-ToF and HPLC-UV, and a statistical analysis was carried out of the questionnaires that were correctly filled out. RESULTS: A total of 513 drug samples have been analyzed. Most consumers were looking for the relaxing/calming effects of heroin and the stimulating effects of cocaine, but they generally overestimated heroin potency and underestimated cocaine potency. No strong correlation based on Spearman's ρ between drug user estimations, drug prices and drug quality was found. CONCLUSION: To the best of our knowledge, this study is the first to combine drug analysis with heroin and cocaine user feedback about expectation, drug prices and drug effects. The analytical results were of great interest for users and the staff working at the drug consumption rooms. They may be a strong supplementary communication tool for health care workers when discussing effects and risks of highly toxic substance consumption.

"The Slums Have To Be Shown": Documenting Drug Injection in Public Spaces Ahead of the Opening of a Drug Consumption Room in Marseille.

EPOSIM is a community-based participatory research study which used the Photovoice method with people who inject drugs (PWID) ahead of a possible opening of a drug consumption room (DCR) in Marseille, France. It aimed to identify the strategies used by PWID when injecting, and the risks they take when they have no safe private space to inject in the area they live in. A total of 7 PWID participated in the full study process. The 189 photographs they took provided us with a good understanding of their injection practices in public places. The main results highlighted the spatiality and materiality of injecting experience in a context where no DCR was available. They also showed the relevance of Photovoice to valorize the voices of PWID when implementing a DCR. Through the showcasing of their photographs at various public exhibitions, the participants seized the opportunity to use Photovoice to make their voices heard beyond the group formed for the study, in order to show the different forms of stigma and insalubrious contexts which they faced on a daily basis. Furthermore, the photographs taken demonstrated that having only health and safety records is not enough to fully understand PWID injection practices. Future studies must take into account PWID perceptions of their relationship with injecting in public spaces and with the management of stigma. The questions of pleasure and comfort must also be explored in evaluation studies of harm reduction measures, for example, DCR.

Peer-assisted injection as a harm reduction measure in a supervised consumption service: a qualitative study of client experiences.

BACKGROUND: Peer assistance is an emerging area of study in injection drug use. When Canada's first supervised consumption site (SCS) opened in 2003 in Vancouver, Canada, clients were prohibited from injecting their peers; only recently has this practise been introduced as a harm reduction measure at these sites. In 2018, Health Canada granted federal exemption to allow peer-assisted injection at certain SCS sites, under the Controlled Drugs and Substances Act. Literature pertaining to peer-assisted injection addresses several topics: interpersonal relationships between the injection provider and recipient; the role of pragmatism; trust and expertise; and gender relations. METHODS: In this qualitative study, participants (n = 16) were recruited to be interviewed about their experiences in a peer-assisted injection program (PAIP) at one SCS regulated by Health Canada. Interview data were transcribed and thematically analyzed. Quantitative administrative data were used to provide context and to describe the study population, comprised of people in the PAIP (n = 248). RESULTS: PAIP clients made up 17.4% of all SCS clients. PAIP clients were more likely to be female and Indigenous. Injection providers expressed being moved by compassion to help others inject. While their desire to assist was pragmatic, they felt a significant burden of responsibility for the outcomes. Other prominent factors related to the injection provider-recipient relationship were social connection, trust, safety, social capital, and reciprocity. Participants also made suggestions for improving the PAIP which included adding more inhalation rooms so that if someone was unable to inject they could smoke in a safe place instead. Additionally, being required by law to divide drugs outside of the SCS, prior to preparing and using in the site, created unsafe conditions for clients. CONCLUSIONS: Regular use of the SCS, and access to its resources, enabled participants to lower their risk through smoking and to practice lower-risk injections. At the federal level, there is considerable room to advocate for allowing clients to divide drugs safely within the SCS, and to increase capacity for safer alternatives such as inhalation.

To what extent do supervised drug consumption services incorporate non-injection routes of administration? A systematic scoping review documenting existing facilities.

BACKGROUND: Most of the existing research on supervised consumption services (SCS) is focused on injection drug use. Less is known about the applicability of SCS for people who consume drugs orally, intranasally, or through inhalation. This is problematic because people who use drugs through modes other than injection are also at risk of overdose death and other harm, and experience barriers accessing health and social services. We aimed to describe existing SCS models that accommodate these alternate routes of drug consumption, and synthesize available information on characteristics of program participants. METHODS: We conducted a systematic scoping review of 9 peer-reviewed and 13 grey literature databases on SCS that incorporate non-injection routes of consumption. We screened 22,882 titles, and excluded 22,843 (99.8%) articles. We ultimately included 39 (0.2%) full-text articles; 28 (72%) of these articles explicitly identified SCS that permit alternate routes of consumption and 21 (54%) discussed characteristics of participants who consume drugs through non-injection routes. Data on study characteristics, terms and definitions, and site and program participant characteristics were extracted and double-coded. Extracted data were analyzed using descriptive statistics and narrative synthesis. RESULTS: Included articles describe 48 SCS that permit non-injection routes of consumption, most of which were located in Germany. The majority of these SCS were legally sanctioned and had models of care that were largely comparable to supervised injection services. Notable differences included physical infrastructure such as ventilated rooms or outdoor areas to accommodate inhalation, and shorter time limits on non-injection drug consumption episodes. Program participants engaging in non-injection forms of consumption were typically men over the age of 30 and structurally vulnerable (e.g., experiencing homelessness or unstable housing). CONCLUSIONS: Extant academic and grey literature indicates that site characteristics and demographics of program participants of SCS that permit non-injection routes of consumption largely reflect those of supervised injection services. Further research on the range of existing SCS that incorporate non-injection routes of consumption is needed to ensure high quality service provision, and improved health outcomes for people who consume drugs via oral, intranasal, and inhalation routes.

Prospective client survey and participatory process ahead of opening a mobile drug consumption room in Lisbon.

BACKGROUND: Ahead of opening Portugal's first mobile drug consumption room (MDCR) in Lisbon, information from People Who Use Drugs (PWUD) and local community members was necessary to determine current needs and shape the intervention. A participatory and peer-led process was ensured at all stages of data gathering and planning of the intervention. METHODS: Prospective clients were surveyed to determine their willingness to use the service and preferences for use and to gain sociodemographic information. Persons over the age of 18 who reported injection drug use (PWID) were recruited using convenience sampling in the main open drug use scenes in Lisbon. In-person interviews were conducted by trained peer workers between November and December of 2017. The results (n = 72) of the questionnaires were analyzed, providing descriptive statistics. RESULTS: There is a high level of willingness to use the MDCR, primarily for reasons of hygiene, privacy, and security. Most participants expressed a desire to use the MDCR daily. Potential clients are socially marginalized, and many suffer from unstable housing. Most are daily users and engage in unsafe injecting practices, such as public injecting and material sharing. High levels of hepatitis C, HIV, and hepatitis B were observed among the target population with low levels of healthcare access and utilization. Preferences were gauged regarding the scheduling of the MDCR's hours and amount of time willing to travel to reach the MDCR and will be taken into account for implementation. The combination of high levels of willingness to utilize the service and high levels of need among the target population support the implementation of Lisbon's first MDCR. CONCLUSIONS: Continual participation of PWUD and other community members will be necessary to maximize the public health and social impacts of this intervention, relative to this baseline. The plan to continue the participatory and peer-led development of the MDCR includes integrating peer workers, clients, and local community members within the operation, management, and evaluation of the service. This research adds to a growing literature about drug consumption rooms (DCRs) in Europe, which is especially limited concerning MDCRs.

Opinion of health professionals and drug users before the forthcoming opening of the first drug consumption room in Paris: a quantitative cross-sectional study.

BACKGROUND: On the brink of the opening of the first French drug consumption room in Paris, the general opinion of the local involved health care professionals and drug users was not known. The objective of this study was to determine their expectations and to search for influencing factors. METHOD: We carried out a quantitative cross-sectional study. A multiple choice questionnaire was proposed to the surrounding willing general practitioners (GPs) and pharmacists, to the emergency doctors of Lariboisière hospital, and to the professionals of the harm reduction facilities and their drug users (PWUD). For each question, there was a choice between seven answers, from "- 3" (very negative impact) to "+ 3" (very positive impact). The influence of the characteristics of each group on its mean answers was explored by Mann-Whitney, Kruskal-Wallis, and Spearman's tests. RESULTS: The median expectations among the groups of responding GPs (N = 62), other health care professionals (N = 82), and PWUD (N = 57) were mainly positive. They thought that the drug consumption room (DCR) would improve the health of PWUD, reduce their at-risk behaviors, would not increase drug use or drug dealing in the neighborhood, and would reduce nuisance in the public space. Only the group of GPs expressed that the DCR could decrease the quietness of the neighborhood, and only the group of PWUD had higher expectations that the DCR would decrease the number of arrests and the number of violent behavior. GPs' expectations were significantly better in terms of health improvement of PWUD and reducing their precariousness if they had a previous experience in addiction medicine (Mann-Whitney, p = 0.004 and p = 0.019), with a longer practice (Spearman's rho, p = 0.021 and p = 0.009), and if they were currently prescribing opioid substitution treatments (Mann-Whitney, p = 0.030 and p = 0.002). Among non-GPs, those who were working in addiction medicine centers had significantly better expectations than pharmacists, and the professionals of the local emergency department had intermediate expectations. CONCLUSIONS: Health care professionals and drug users had a positive opinion of the to-be-created Parisian drug consumption room. Experience in addiction medicine influenced positively health professionals' expectations.

A cross-sectional national survey assessing self-reported drug intake behavior, contact with the primary sector and drug treatment among service users of Danish drug consumption rooms.

BACKGROUND: Drug consumption rooms (DCRs) have been implemented worldwide as a harm-reducing strategy. In 2012, Denmark passed legislation allowing establishment of DCRs. The aim of this study was to identify characteristics and gain knowledge of the way service users use the DCRs including bridge building to specialized health care. Associations between nationality, opioid substitution treatment (OST), drug intake method, and response to staff advice on harm-reducing education was investigated, as well as service user's reasons for using the DCRs, and their perceptions of safety and trust in the DCRs. METHODS: A survey questionnaire sampled 154 participants of DCRs. Convenience sampling was used. Key variables covered demographics, drug intake mode, educational advice received in the DCR, and opinions about and role of the DCRs for the service users. RESULTS: Only 10 % of the participants were under the age of 30, 30 % between 30 and 39 years, 36 % between 40 and 49 years, and 24 % age 50 or more. A total of 60 % of the participants had encountered drugs before they were 19 years old. Female participants were 25 %, and 73 % were Danish citizens, 8 % were non-Danish EU citizens, and 18 % were non-EU citizens. As drug intake method, 63 % injected drugs in a vein, 7 % sniffed, and 37 % smoked. Of drugs used in the DCR, 49 % used cocaine, 41 % heroin, 16 % a mix of heroin and cocaine, and 16 % used methadone. Participants who smoked drugs made significantly less use of drug rehabilitation than participants who sniffed or injected drugs. There was a similar rate of advice on OST across nationality. Participants accepted staff education on hygienic measures and safe injection practices and found it useful. Participants felt safe and trusted staff and bridge building to specialized health care took place in the DCR. CONCLUSIONS: Staff of Danish DCRs educate service users on health related issues and harm-reducing interventions. A subgroup who smoke and a subgroup of nationality other than Danish are underserved and have less likely been in OST. More research on these groups is needed.

Changes in Australians' attitudes towards supervised injecting facilities.

INTRODUCTION: Supervised injecting facilities (SIF) have been shown to reduce negative outcomes experienced by people who inject drugs. They are often subject to intense public and media scrutiny. This article aimed to explore population attitudes to SIFs and how these changed over time in Australia. METHODS: Data were drawn from the National Drug Strategy Household Survey, a national sample collecting data on illicit drug use and attitudes towards drug policy among Australians (2001-2019). Ordinal logistic regression assessed sociodemographic characteristics associated with different attitudes to SIFs and binary logistic regression assessed trends over time and by jurisdiction. RESULTS: In 2019, 54% of respondents (95% CI 52.9, 55.1) supported SIFs, 27.5% (95% CI 26.6, 28.4) opposed and 18.4% (95% CI 17.7, 19.2) were ambivalent. Support for SIFs correlated with having a university degree (OR 1.75; 95% CI 1.58, 1.94), non-heterosexual identity (OR 1.81, 95% CI 1.51, 2.17) and recent illicit drug use (OR = 1.74, 95% CI 1.55, 1.94). Male respondents or those living in socioeconomically disadvantaged areas had lower odds of supporting SIFs (OR 0.92, 95% CI 0.85, 1.00; OR 0.64-0.80, respectively). Between 2001 and 2019, support for SIFs increased modestly by 3.3%, those who 'don't know' by 7.4%, whereas opposition decreased by 11.7%. Between 2001 and 2019, support for SIFs increased in NSW and Queensland, whereas opposition decreased in all jurisdictions. DISCUSSION AND CONCLUSIONS: Opposition to SIFs declined over the past 20 years, but a substantial proportion of respondents are ambivalent or 'don't know enough to say'. Plain language information about SIFs and their potential benefits, targeted to those who are ambivalent/'don't know' may further increase public support.

Barriers and facilitators of naloxone and safe injection facility interventions to reduce opioid drug-related deaths: A qualitative analysis.

BACKGROUND: Opioid drug-related deaths continue to be a significant public health concern in the Republic of Ireland (ROI) and Northern Ireland (NI). While both regions have implemented naloxone to reduce drug related deaths, there remains a gap in the implementation of a supervised injection facility (SIF). This study aimed to identify barriers and facilitators to implementing naloxone and a SIF to reduce opioid drug-related deaths in ROI and NI. METHODS: Semi-structured interviews (n=23) were conducted in ROI and NI with experts by experience (n=8), staff from low threshold services (n=9), and individuals involved in policy making (n= 6). Data were analyzed using coding reliability Thematic Analysis and were informed by the Risk Environmental Framework. RESULTS: The findings illustrated that stigma within the media, health centers, and the community was a significant barrier to naloxone distribution and SIF implementation. Policing and community intimidation were reported to hinder naloxone carriage in both the ROI and NI, while threats of paramilitary violence towards people who use drugs were unique to NI. Municipal government delays and policy maker apathy were reported to hinder SIF implementation in the ROI. Participants suggested peer-to-peer naloxone delivery and amending legislation to facilitate non-prescription naloxone would increase naloxone uptake. Participants recommended using webinars, Town Halls, and a Citizens' Assembly as tools to advocate for SIF implementation. CONCLUSION: Local and regional stigma reduction campaigns are needed in conjunction with policy changes to advance naloxone and a SIF. Tailoring stigma campaigns to incorporate the lived experience of people who use drugs, their family members, and the general community can aid in educating the public and change negative perceptions. This study highlights the need for ongoing efforts to reduce stigma and increase accessibility to evidence-based interventions to address opioid drug-related deaths in the ROI, NI, and internationally.

Community perceptions surrounding Lisbon's first mobile drug consumption room.

Portugal's first Mobile Drug Consumption Room (MDCR) has been operating for over three years in two Lisbon neighborhoods. This qualitative study first creates a baseline understanding of community perceptions concerning the acceptability of and expectations surrounding drug consumption rooms in the communities of intervention. Then, at least six months after the initial interviews, it determines how these perceptions changed and what changes participants perceive in the neighborhoods. Findings highlight widespread acceptance of the MDCR among participants. One of the participants' priorities related to the MDCR was to lessen the visibility of public consumption, a change some participants perceived in the neighborhood. While in the first round of data collection participants primarily conceptualized the MDCR as a service for People Who Use Drugs (PWUD), in the follow-up round, they reported changes in the community.

The United Kingdom's first unsanctioned overdose prevention site; A proof-of-concept evaluation.

BACKGROUND: The United Kingdom (UK) is currently experiencing a public health crisis of drug-related deaths. The government has rejected recommendations to open overdose prevention services, under the Misuse of Drugs Act 1971. To report on the operation and use of an unsanctioned overdose prevention service which operated in Glasgow city centre from September 2020 to May 2021. METHODS: Description of the service, with analysis of data collected on its use. RESULTS: The service operated for nine months without permission or funding from official sources. We report on the 894 injections supervised and recorded, and nine successful interventions with overdose events (seven opioid/two cocaine). Powder cocaine injection predominated either alone (60.6%) or with heroin (22.1%). Injection was mostly in the groin (68.0%) or arm (16.8%). More injections were recorded by males (70.1%). Around 65% of injection events featured an individual who was on a buprenorphine/methadone prescription. CONCLUSION: It is feasible for an overdose prevention service to operate successfully in the UK without being shut down by the police or with negative consequences for the community. Future sites in the UK must tailor to the substances used by their potential clients, international trends (e.g. for fentanyl use) did not apply here. There is an urgent need and demand for these services in the UK to reduce harm, prevent and intervene during overdose, and provide vital psychosocial support for health and wellbeing in a highly marginalised population.

The state of science on including inhalation within supervised consumption services: A scoping review of academic and grey literature.

BACKGROUND: Internationally, many supervised consumption services (SCS) include drug inhalation (smoking). However, most research is focused on SCS for people who inject drugs. We aimed to: (1) synthesize the literature on including inhalation or other forms of non-injection drug use (e.g., oral, intranasal) within SCS; (2) describe the state of the science on the feasibility of this practice and its outcomes; and (3) outline an agenda for future evaluation research in this area. METHODS: We searched 9 academic and 13 grey literature databases and ultimately included 40 studies. Thirty-two studies (80%) reported findings from feasibility or needs assessments. From these studies, we extracted information on willingness to use these services, perspectives of people who use drugs and other stakeholders, and recommendations for implementation. Eight studies (20%) evaluated including inhalation in SCS, from which we extracted data on associated outcomes. Data were analysed using narrative synthesis and descriptive statistics. RESULTS: We found high willingness to use SCS including inhalation among people who use drugs, especially those experiencing structural vulnerability. Research emphasized a need for implementation to account for the social nature of drug inhalation, and to limit potential occupational hazards associated with passive inhalation. Positive outcomes associated with inhalation within SCS included improved health and safety of people who use drugs and decreased public drug use. However, this evidence was based primarily on a limited number of studies with designs of mixed quality. CONCLUSION: Our review demonstrates feasibility of, and need for, implementing SCS including inhalation, and some potential positive outcomes associated with this practice. However, more comprehensive and systematic evaluations of including inhalation as well as other forms of non-injection drug use (e.g., oral, intranasal, rectal) within SCS should be conducted.

Community perspectives on supervised consumption sites: Insights from four U.S. counties deeply affected by opioids.

BACKGROUND: To address the overdose crisis in the United States, expert groups have been nearly unanimous in calls for increasing access to evidence-based treatment and overdose reversal drugs. In some places there have also been calls for implementing supervised consumption sites (SCSs). Some cities-primarily in coastal urban areas-have explored the feasibility and acceptability of introducing them. However, the perspectives of community stakeholders from more inland and rural areas that have also been hard hit by opioids are largely missing from the literature. METHODS: To examine community attitudes about implementing SCSs for people who use opioids (PWUO) in areas with acute opioid problems, the research team conducted in-depth interviews and focus groups in four counties: Ashtabula and Cuyahoga Counties in Ohio, and Carroll and Hillsborough Counties in New Hampshire, two states with high rates of opioid overdose. Participants were policy, treatment, and criminal justice professionals, frontline harm reduction and service providers, and PWUO. RESULTS: Key informants noted benefits to SCSs, but also perceived potential drawbacks such as that they may enable opioid use, and potential practical barriers, including lack of desire among PWUO to travel to an SCS after purchasing opioids and fear of arrest. Key informants generally believed their communities likely would not currently accept SCSs due to cultural, resource, and practical barriers. They viewed publication of evidence on SCSs and community education as essential for fostering acceptance. CONCLUSIONS: Despite cultural and other barriers, implementation of SCSs may be more feasible in urban communities with existing (and perhaps more long-standing) harm reduction programs, greater treatment resources, and adequate transportation, particularly if there is strong evidence to support them.

Atmospheres of engagement within a German drug consumption room.

Drug consumption rooms directly attempt to intervene in and govern the place and time of drug use. Whilst the risk-reducing potentials of these interventions have been thoroughly evaluated, the consumption room literature offers fewer insights into the embodied, affective and situated dynamics that underscore service delivery. In this paper, we take up the notion of atmosphere to explore these dynamics in greater depth. Drawing on 12 months of ethnographic research in a German drug consumption room, we describe the manner in which atmospheres came to pervade and condition service encounters. More than simply providing texture to activities within the consumption room, we show how atmospheres gave rise to a distinct range of bodily capacities and therapeutic effects. Critically, these atmospheric affordances exceeded the risk-reducing objectives of the consumption room to encompass an emergent capacity to find repose, enact respite and foster modes of sociality and care. Our analysis further highlights the contextual contingencies through which the atmospheres of the consumption room emerged, including the efforts of both staff and clients to cultivate and control particular atmospheric qualities. We conclude by considering how closer attention to the atmospheric and affective dimensions of service delivery may challenge how consumption room interventions are enacted, valued and researched. This is to gesture towards a novel, atmospheric mode of harm reduction that has effects by transforming embodied potentials for both staff and clients.

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada.

BACKGROUND: There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender. METHODS: Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender. RESULTS: Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men. CONCLUSION: Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

How to overcome political and legal barriers to the implementation of a drug consumption room: an application of the policy agenda framework to the Belgian situation.

BACKGROUND: For more than 30 years, drug consumption rooms (DCRs) have been implemented in Western countries. DCRs are supported by a large body of evidence about public safety and public health effectiveness. However, a political consensus has never been achieved in Belgium on amending the existing law that explicitly penalises the supply of a room for facilitating drug use. Despite this adverse legal and policy framework, a DCR opened in the city of Liège in 2018. In this case report, we applied the theoretical framework proposed by Shiffman and Smith for policy agenda setting, in order to describe and assess how political and legal barriers were overcome in the process of opening the DCR. CASE PRESENTATION: For some years, fieldworkers and some city policymakers argued for DCR implementation in Belgium, but without gaining the support of the national authorities, mainly for ideological reasons. In order to address this debate, a feasibility study of DCR implementation in Belgian cities was commissioned. At the national level, an institutional debate took place about the political responsibility for DCRs as a public health intervention, as health care is mainly a matter of regional policy. The lack of consensus led to a situation of political deadlock. Meanwhile, the publication of the study report and the context of local elections offered an opportunity for Liège authorities to reignite the local debate on DCRs. At the local level, law enforcement, care professionals, residents, users, and the press were all involved in the implementation process. Therefore, a local consensus was formed and despite the absence of any national legal change, the DCR opened 1 month before the local elections. It has been working without major medical or legal incident since then. Incidentally, the mayor of Liège was re-elected. CONCLUSIONS: Although the lack of a legal framework may engender instability and affect longer-term effectiveness, the DCR implementation in Liège was successful and was based on a local consensus and effective communication rather than on an appropriate legal framework. The experience provides lessons for other cities that are considering opening a DCR despite an adverse legal and political context.

Integrating smoking cessation care into routine service delivery in a medically supervised injecting facility: An acceptability study.

BACKGROUND: Among people who inject drugs (PWIDs) the prevalence of tobacco smoking exceeds 80%; making smoking cessation intervention a priority for this population. This study aims to examine staff and client perspectives from a supervised injecting facility regarding: i) whether an organizational change intervention increased rates of smoking cessation care delivery (pre- to post-intervention); and ii) acceptability of the intervention. METHODS: A pre-and-post intervention pilot study in a supervised injecting facility was conducted in Sydney, Australia between July 2014-December 2015. The intervention employed an organizational change approach and included six components. Cross-sectional samples of staff (pre n = 27, post n = 22) and clients (pre n = 202, post n = 202) completed online surveys pre and post intervention. RESULTS: From pre to post-intervention staff reported smoking cessation practices significantly increased for the provision of verbal advice (30% to 82%; p < 0.001), offer of free or subsidized nicotine replacement therapy (30% to 91%; p < 0.001), referral to a general practitioner (19% to 64%; p = 0.001), and follow-up to check on quit smoking progress (18.5% to 64%; p = 0.001). Significantly more clients reported receiving all smoking cessation strategies post-intervention. Over 85% of staff agreed that it was acceptable to address client smoking as part of usual care and 95% of clients agreed that it was acceptable to be asked by staff about their tobacco smoking. CONCLUSIONS: Increasing the provision of smoking cessation care using an organizational change approach is both feasible for staff and acceptable to staff and clients of supervised injecting facilities.

'Enjoying the kick': Locating pleasure within the drug consumption room.

BACKGROUND: Harm reduction policy and praxis has long struggled to accommodate the pleasures of alcohol and other drug use. Whilst scholars have consistently highlighted this struggle, how pleasure might come to practically inform the design and delivery of harm reduction policies and programs remains less clear. The present paper seeks to move beyond conceptual critiques of harm reduction's 'pleasure oversight' to more focused empirical analysis of how flows of pleasure emerge, circulate and, importantly, may be reoriented in the course of harm reduction practice. METHODS: We ground our analysis in the context of detailed ethnographic research in a drug consumption room in Frankfurt, Germany. Drawing on recent strands of post-humanist thought, the paper deploys the concept of the 'consumption event' to uncover the manner in which these facilities mediate the practice and embodied experience of drug use and incite or limit bodily potentials for intoxication and pleasure. RESULTS: Through the analysis, we mapped a diversity of pleasures as they emerged and circulated through events of consumption at the consumption room. Beyond the pleasurable intensities of intoxication's kick, these pleasures were expressed in a range of novel capacities, practices and drug using bodies. In each instance, pleasure could not be reduced to a simple, linear product of drug use. Rather, it arose for our participants through distinctive social and affective transformations enabled through events of consumption at the consumption room and the generative force of actors and associations of which these events were composed. CONCLUSION: Our research suggests that the drug consumption room serves as a conduit through which its clients can potentially enact more pleasurable, productive and positive relations to both themselves and their drug use. Acknowledging the centrality of pleasure to client engagement with these facilities, the paper concludes by drawing out the implications of these findings for the design and delivery of consumption room services.

Supervised injection services: what has been demonstrated? A systematic literature review.

BACKGROUND: Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking. AIMS: To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm. METHODS: A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")]. RESULTS: Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney. CONCLUSION: SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.